Surgeons get onside with new operating room rules

Dr. Bryce Taylor, surgeon-in-chief at Toronto's University Health NetworkPhoto by
University Health Network

Dr. Bryce Taylor, surgeon-in-chief at Toronto's University Health Network, knew something had to be done to reduce the staggering number of complications after surgery.

In Canada, 50,000 people a year develop surgical site infections, according to the Ontario Ministry of Health and Long Term Care. By far the greatest number of post-op infections are seeded in the operating room.

The route Taylor took proved to be groundbreaking. Toronto General, one of three hospitals that make up UHN, joined seven others around the world to test the effectiveness of a Surgical Patient Safety Checklist recommended by the World Health Organization.

The study collected data from 3,733 patients for one year before the checklist was tested, then compared that to the outcomes of 3,955 patients after the program was in place.

The results were astonishing. When the surgical teams followed a simple process of pre-operative, before-incision and post-operative briefings, and when the surgical site was clipped not shaved, the complication rate dropped substantially.

The rate fell from an average of 11% to 7% when the checklist was rigorously followed.

"Essentially what we want is no surprises," Taylor says. "We knew anecdotally, for example, that clipping is better than shaving for infection control. Shaving leaves small nicks and they can be packed with bacteria. The real challenge was making sure all surgeons working in all of our 31 operating rooms now follow that checklist" at the UHN's Toronto General, Toronto Western and Princess Margaret hospitals.

That's no easy task, says Dr. Michael Gardam, UHN's medical director for infection prevention and control. Older surgeons especially, he says, are often reluctant to adopt procedures different from those they have been following for decades.

"To get them to clip, not shave, Dr. Taylor simply ordered all razors be removed from operating rooms," Gardam says. "And finally to get everyone to follow the checklist, he threatened to remove operating room time for those that didn't."

The challenge of preventing post-operative infections, which can extend hospital stays for months, rather than just four to five days when no infection occurs, is a significant one.

"Patients today are coming in older, sicker and with more complex diseases than we faced just five years ago," he says. "They also expect more from the health care system. Preventing infection has to be a top priority."

While gains are being made in lowering the number of infections that take hold during surgery, the prevention of superficial infections that take place during recovery continues to rely on decades-old techniques, doctors say. The most commonly used surgical wound dressings, for instance, are awkward for the patient and must be changed regularly.

"One of the chief problems we face is that many surgeons just don't wash their hands or put on new surgical gloves between examining patients on post-op rounds," Gardam says. "They come in, lift the dressing to have a look with bare hands and then go on to the next patient and do the same thing without washing their hands in between.

"I think we all know the infection rates in hospitals are not as low as they could be. They keep coming down but there is still more we can do."

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